Basic Information
| Provider Information | |||||||||
| NPI: | 1407949241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL FACILITIES OF AMERICA LXXV (75) LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEXINGTON HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2917 PENN FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240184374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409893618 | ||||||||
| FaxNumber: | 5407749443 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 CORNELIA ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272924140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362421349 | ||||||||
| FaxNumber: | 3362421380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | CLAUDE | ||||||||
| AuthorizedOfficialMiddleName: | NOVEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO, MFA INC. GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5047767526 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | NH0527 | NC | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 313M00000X | NH0527 | NC | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | NH0527 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 340601P | 05 | NC | MEDICAID | 7801685 | 01 | NC | REST HOME PROVIDER NUMBER | OTHER | 3405419 | 05 | NC | MEDICAID |